Citation Nr: 0004788 Decision Date: 02/24/00 Archive Date: 02/28/00 DOCKET NO. 98-01 150 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an increased rating for a psychiatric disorder, including post-traumatic stress disorder (PTSD), currently rated as 30 percent disabling. 2. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD J. D. Parker, Counsel INTRODUCTION The veteran served on active duty from August 1943 to September 1945. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in December 1997 by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. REMAND The Board has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.159 (1999). This duty to assist involves obtaining relevant medical reports and examinations where indicated by the facts and circumstances of the individual case. See Abernathy v. Principi, 3 Vet. App. 461 (1992); Roberts v. Derwinski, 2 Vet. App. 387 (1992); Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Littke v. Derwinski, 1 Vet. App. 90 (1990); Murphy v. Derwinski, 1 Vet. App. 78 (1990). After careful review of the evidence of record, the Board finds that a remand is necessary. In this veteran's case, the September 1999 VA examination report reflects that, at the time the examination was conducted, the examiner did not have the claims file. Such a medical examination should "take into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." Green (Victor) v. Derwinski, 1 Vet. App. 121, 124 (1991); see also Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991); 38 C.F.R. § 4.2 (1999) ("[i]f a diagnosis is not supported by the findings on the examination report or if the report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes"). In Crawford v. Brown, 5 Vet. App. 33, 36 (1993), in which the claimant sought an increased rating for a service-connected psychiatric disability and was examined by a VA physician who did not review the claimant's prior medical records, the United States Court of Appeals for Veterans Claims (Court) concluded that the evidence before the Board was "inadequate" and remanded the case with instruction to conduct a new examination "which takes into account the records of prior medical treatment, so that the evaluation of the veteran's disability will be a fully informed one." (emphasis in original). Review of medical history was significant in this increased rating case so that the current state of the conditions could be viewed in the context of the progression of the disabilities at earlier stages. VAOPGCPREC 20-95. Additionally, the Board notes that in 1945 the veteran was originally service connected for "dementa praecox, analogy for psychosis, schizophrenia, definite social and industrial incapacity," which was incurred in combat. The veteran's current disability includes diagnoses of PTSD, a probable Axis I recurrent major depression with psychotic features, and alcohol abuse (in remission). In recent rating decisions, the service-connected disability has been characterized as PTSD. There is no medical evidence of record which explains the relationship between, or attempts to reconcile, the 1945 diagnosis with the currently diagnosed psychiatric disorders. A psychiatric medical opinion in this regard would help to clarify the record and assure that all psychiatric symptomatology which results from the veteran's service-connected psychiatric disability(ies) is properly considered in determining the issues at hand. The Court has held that, when the Board makes a determination of individual unemployability for purposes of a total disability rating, it must provide sufficient reasons and bases for its decision, including a clear explanation of the veteran's current degree of unemployability attributable to his or her service-connected disabilities. Cathell v. Brown, 8 Vet. App. 539, 544-545 (1997). In this case, the Board finds that the evidence of record currently does not allow it to fulfill this responsibility. While the VA examiner in September 1999 included as one of Axis IV stressors that the veteran was "unable to work," it does not appear that an opinion has been rendered based on a review of the evidence of record. The opinion did not include whether the veteran was precluded from all forms of substantially gainful employment due to his service-connected psychiatric disabilities. VA has a duty to supplement the record by obtaining an opinion as to the effect that the veteran's service-connected disability has upon his ability to work. See Friscia v. Brown, 7 Vet. App. 294 (1995); Gary v. Brown, 7 Vet. App. 229 (1994). The veteran reported at the personal hearing in August 1999 that he had been receiving disability benefits from the Social Security Administration (SSA). Regardless of whether the benefits were in fact due to old age or disability, it does not appear that any records from SSA have ever been requested or obtained by the RO. Accordingly, the RO should attempt to obtain any records held by SSA pertaining to the veteran. Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992) (appropriate weight and consideration must to given to SSA records in determining whether to award or deny VA disability compensation benefits). The duty to obtain records is particularly applicable to records held by agencies of the Federal Government. See Counts v. Brown, 6 Vet. App. 473 (1994). Under the circumstances, the Board believes that further development should be accomplished to allow for resolution of the increased rating for service-connected psychiatric disability, including PTSD, and TDIU issues. Accordingly, the case is REMANDED to the RO for the following actions: 1. All VA medical records (not already of record) documenting ongoing treatment for service-connected PTSD or other psychiatric disorders should be associated with the claims file. 2. The RO should contact the veteran to determine the names, addresses, and dates of treatment of any and all medical care providers who treated the veteran for PTSD or other psychiatric disorder. After securing the necessary release, the RO should obtain these records. All correspondence, as well as any medical or treatment records obtained, should be made a part of the claims folder. 3. The RO should also contact the Social Security Administration and obtain any decisions awarding disability benefits, as well as any supporting medical evidence. 4. The veteran should be afforded a VA psychiatric examination to determine the degree of severity of his service- connected psychiatric disorder, which includes PTSD, and its impact on his ability to obtain and maintain employment. The claims folder should be made available to the examiner prior to the examination so that he or she may review pertinent medical records. Such tests as the examining physician deems necessary should be performed. A multiaxial diagnosis based on the current DSM-IV diagnostic criteria is required, including a Global Assessment of Functioning Score. In addition, it is requested that the psychiatrist address the relationship between the veteran's originally service- connected disorder of "dementa praecox, analogy for psychosis, schizophrenia, definite social and industrial incapacity," which was related to combat, and his currently diagnosed disorders of PTSD, recurrent major depression with psychotic features, and alcohol abuse (in remission), and offer an opinion as to which, or if all, of the currently diagnosed disorders are etiologically the same or related to the earlier diagnoses for which service connection was established. The examiner should identify diagnostically all symptoms and clinical findings which are manifestations of the service-connected psychiatric disorder(s), which includes PTSD and render an opinion for the record as to the degree to which those specific symptoms and findings affect the veteran's ability to establish and maintain effective and favorable relationships with people (social impairment), and the degree to which they affect his reliability, productivity, flexibility, and efficiency levels in performing occupational tasks (industrial impairment). See Massey v. Brown, 7 Vet. App. 204 (1994). If any psychiatric disability is found which is not a part of the veteran's service-connected psychiatric disorder(s), the examiner should also render an opinion as to the effect the veteran's service-connected disorder(s) alone has(have) on his ability to work, making a distinction between any social and industrial impairment stemming from the service- connected disability and any non-service- connected psychiatric disability. 5. Following completion of the above actions, the RO must review the claims folder and ensure that all of the foregoing development has been conducted and completed in full. If the report is deficient in any manner, it must be returned to the examiner for corrective action. 38 C.F.R. § 4.2 (1999); see also Stegall v. West, 11 Vet. App. 268 (1998). 6. The veteran has a right to present any additional evidence or argument while the case is in remand status. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). If the benefit requested on appeal is not granted, the RO should issue a supplemental statement of the case to the veteran and his representative, and a reasonable period of time for a response should be afforded. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. By this REMAND, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. R. F. WILLIAMS Member, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 1991 & Supp. 1999), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1999).